MNP 694C Soap Note

SOAP NOTE

 

A SOAP note for psychiatry is a little different than a SOAP note for a medical patient, but the basic format and premise is the same.  It is a communication between the treating clinician and the next treating clinician as well as other members of the care team. It is also something that the insurance company or payor source may want to look at to determine if the patient requires this level of care. A SOAP note is a part of the Chart, a legal document, and is to be treated as such. It is not the initial documentation on a patient, it is after the patient has been seen and an initial psychiatric evaluation has been done.

 

This is a pretty good example for you to use for preparing a SOAP NOTE. If your facility uses one you like better, that is fine. Following the information from a patient interview, a chart review; upload your note to Blackboard as directed.

 

 

SOAP NOTES:

Date and Time

Name and Credentials of person writing this note:

ALSO LIST MEDS AND DOSES on a separate sheet as if on a MAR

Significant Events:   Over past 24 hours

Subjective (S):               Use the patient’s own words as much as possible

  • Vegetative symptoms (sleep, appetite, concentration/energy, anxiety, etc.)
  • Patient’s complaints, pain, medication side effects
  • Requests

 

Objective (O):

  • Labs (admit labs of first day, new results, or new labs ordered)
  • Studies (CXR, ECG, US, neuropsychological testing, etc.)

 

MENTAL STATUS EXAM (MSE):

Appearance

Behavior

Speech

Mood

Affect

Thought Process

Thought Content

Insight

Judgment

Cognition

Assessment (A):  1-2 sentence summary of

  • Patient profile: age, M/F, race, occupation, marital status
  • Diagnosis differential
  • Diagnosis: Psychiatric and Medical
  • Prognosis
  • Treatment and tolerance, side effects, improvement

 

Plan (P):       List by diagnosis or problem (medication strategy, planned tests, social work issues,

discharge plans)

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